Healthcare Provider Details

I. General information

NPI: 1902750573
Provider Name (Legal Business Name): REFRESH AND RENEW WITH NURSE HENDERSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2026
Last Update Date: 02/23/2026
Certification Date: 02/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 RED BUCKEYE CT
MONCKS CORNER SC
29461-8600
US

IV. Provider business mailing address

1208 RED BUCKEYE CT
MONCKS CORNER SC
29461-8600
US

V. Phone/Fax

Practice location:
  • Phone: 623-204-6631
  • Fax:
Mailing address:
  • Phone: 623-204-6631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: IRULAN HENDERSON
Title or Position: CLINICIAN
Credential: NP
Phone: 623-204-6631